NN&I - August 2010

Timmy Lee, MDVascular Access Update August 2010 Nephrology News & Issues 29Subscribe to our free eNewsletter at www.nephronline.comStudy looks at ways to increase AVF placementBy Cynthia Roberts, RN, CNNStarting patients on dialysis with a per-manent vascular access continues to be a challenge, and the successes (and failures) vary widely across the country. The National Kidney Foundation and the Kidney Disease Outcomes Quality Initiative vascular access guidelines have set the goal of having 50% of inci-dent patients initiating hemodialysis with a functional fistula. Many barriers and challenges exist, such as educating patients about advanced chronic kidney disease, untimely referral to nephrologists and vascular access surgeons, a lack of long term management strategies, and a lack of evidenced-based practice models. A vascular access team approach, whether it is in a hospital setting, vascular access center, or outpatient hemodialysis setting, is a logical and ideal solution. However, this model demands commitment, dedication, and a vision that has to be supported financially and requires team members with a desire and passion for vascular access care of the patient. In June, nephrologist Timmy Lee at the University of Cincinnati received the Franklin McDonald Fresenius Medical Care Young Investigator Research Award to conduct an observa-tional study at the Cincinnati Veterans Administration (VA) Medical Center. The study's goal is to learn what impact early referral and a dedicated focus of vascular access care in patients with advanced chronic kidney disease has on the rate of incident fistula use. His study will evaluate the role of a newly created multidisciplinary clinic on inci-dent fistula use compared to a histori-cal control group. Dr. Lee is an assistant professor of clinical medi-cine, Division of Nephrology and Hypertension at the University of Cincinnati. NN&I asked him to summarize some of the key features of the study. NN&I: How will you identify barriers preventing early referral from primary care to a nephrologist? Lee: That has always been a tough bar-rier, but I believe early referral from our primary care physicians has improved. The most important impact (and great-est barrier) is obtaining timely referral from the nephrologist to the access surgeon. As a nephrologist, I take the responsibility for that process, which includes patient education and prepa-ration for treatment options; vein pres-ervation; vessel mapping; access educa-tion; and preparation for access surgery. Follow-up management of the access is also important. I have to ensure that my patients receive this intense educa-tion from the entire team. NN&I: Tell us a little more about the multidisciplinary team and do you have a formal education program in place? Lee: It is being developed. Our study will be evaluating incident fistula outcomes of a pre-ESRD multidisci-plinary clinic, with members including a nephrologist, vascular access coor-dinator, dietitian, and social worker. Furthermore, during the patient's clinic visit, there will be an opportunity for the patient to meet with the surgeon and have vessel mapping scheduled. All the team members will be able to implement vascular access patient education in a consistent and timely manner, improving team communica-tion as well, and hopefully improving fistula outcomes. NN&I: Can you talk a little about your post-op management of the fistula? Lee: We rely on physical exam of the fistula to guide us, using techniques established by Dr. Michael Allon at the University of Alabama. Of course, ultrasound and fistulo-grams will be utilized when indicated, based on physical exam abnormali-ties. Since these visits are done with the multidisciplinary team, the sur-geon and vascular access coordinator will work together on an individual patient access plan that will be ongo-ing. This should improve the percent-age of patients starting hemodialysis with a functional fistula. The surgeon and the vascular access nurse will be Ms. Roberts is the editor of NN&I's recurring Vascular Access Update section. She is also vascular access coordinator for Renal Research Institute dialysis services at the University of North Carolina/Chapel Hill. [ DR. LEE INTERVIEW , continued on page 33 ] Conference Update Controversies in Dialysis \037Access Oct. 28-29 The Westin St. Francis, San Francisco Info: www.dialysiscontroversies.org37th Annual Symposium on \037Vascular and Endovascular IssuesNov. 17-21 New York City Info: www.veithsymposium.orgCincinnati Hemodialysis Vascular \037Access Symposium Oct. 1-2 Marriott Kingsgate Conference Center Cincinnati Info: Rosemary Rahn at rahnr@ucmail.uc.edu VascularAccess_0810_14.indd 29 7/16/10 1:48:48 PM